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Basic Closed Rhinoplasty

Updated: Mar 22, 2016
Author: A John Vartanian, MD, MS, FACS; Chief Editor: Mark S Granick, MD, FACS more...

OVERVIEW

Background
Rhinoplasty describes an array of operative techniques that can be used to alter the aesthetic and
functional properties of the nose. [1] Surgical access to the nose can be gained via incisions placed
inside the nose (endonasal approaches) or via incisions placed inside the nose combined with
incisions placed outside the nostrils (external approach), usually on the columella. Prior to the
increased popularity of the external (open) rhinoplasty approach in the last decade, the terms
rhinoplasty and endonasal rhinoplasty were almost synonymous. This somewhat artificial division
between external (open) and endonasal (closed) rhinoplasty has become an established part of
current rhinoplasty nomenclature. Despite this, both approaches share many of the same incisions,
and many of the same principles apply regardless of the approach chosen.

Proponents of endonasal rhinoplasty emphasize the following advantages:

Decreased need for surgical dissection

Decreased potential for nasal tip support reduction
Reduced postoperative edema
Corresponding decrease in the potential for overall scarring or iatrogenic insult to the nose
Ability to make exacting changes in situ
Via tactile palpation, a more immediate and predictable ability to feel changes made to the
nose
Ability to make targeted improvements without taking the nose apart
Shorter operative times
Theoretical reduction in morbidity, especially in older patients
Elimination of any risk (however minimal) for developing a visible external columellar scar
Reduced postoperative edema
Quicker return to a normal appearance

The experienced rhinoplasty surgeon can use either an endonasal or an external rhinoplasty
approach, based on the patient's rhinoplasty indications. [2] This article is a basic review of
endonasal rhinoplasty techniques and concepts. The reader is encouraged to read the many high-
yield articles and books listed in the Bibliography.

History of the Procedure

The history of nasal surgery is indeed long. The Edwin Smith surgical papyrus from ancient Egypt
outlines the diagnosis and treatment of nasal deformities some 30 centuries ago. [3] In
approximately 800 BCE, Sushruta, of India, described a nasal reconstruction approach based on
the transfer of a pedicled forehead skin flap. [4] In the 16th century, Tagliacozzi of Bologna, Italy,
used brachial-based delayed flaps to reconstruct noses. The science and art of rhinoplasty
remained essentially stagnant until the 19th century. Approaches to correcting nasal deformities
were used by early plastic surgery pioneers such as Dieffenbach in the 1840s, who used a buried
forehead flap to cover the nasal dorsum. [5]
The first published account of a modern endonasal rhinoplasty can be traced to an American
otolaryngologist, John Orlando Roe. His original article published 1887 was titled "The deformity
termed 'pug-nose' and its correction, by a simple operation" and described the treatment of saddle
nose deformities. [6] In 1892, Robert F. Weir, another American surgeon, also published his
techniques for correcting the saddled nose. [7]

In 1898, Jacques Joseph, an orthopedic surgeon by training, presented his revolutionary concepts
of nasal surgery to the Medical Society of Berlin. Many aspiring rhinoplasty surgeons traveled to
Germany to watch Joseph perform his rhinoplasties. His general reputation as the father of modern
rhinoplasty can be supported by his influence in shaping many rhinoplasty concepts and
techniques. In fact, many of the basic rhinoplasty maneuvers remain essentially the same today as
when Joseph first described them. Joseph's concepts and techniques were further disseminated
(especially in the United States) by surgeons such as Gustav Aufricht, Joseph Safian, and Samuel
Fomon. Fomon's teachings and medical review courses on endonasal rhinoplasty helped in the
education of countless early modern rhinoplasty surgeons, such as Maurice Cottle of Chicago and
Irving Goldman of New York.

In the relatively short history of modern rhinoplasty, many additional rhinoplasty masters have
contributed to the advancement of the field. Countless surgeons continue to advance our
understanding of the art and science of rhinoplasty through their scholarly and clinical works. The
continued sharing and dissemination of rhinoplasty knowledge has hopefully benefited the patient
and surgeon alike.

Problem
Most patients seek rhinoplasty surgery to improve the aesthetic features of the nose. Others may
elect to have a rhinoplasty for functional improvement of the nasal airway. Most often, both
cosmetic and functional issues are addressed during rhinoplasty.

Etiology
Etiologies of nasal deformity can be (1) hereditary/familial (eg, large dorsal hump), (2) traumatic
(eg, after a motor vehicle accident), (3) iatrogenic (eg, unfavorable result from previous
rhinoplasty), or (4) congenital (eg, cleft palate nasal deformity).

Pathophysiology
Septal deviation, inferior turbinate hypertrophy, deviated nasal bones, and narrow internal nasal
valve area can all negatively impact the nasal airway. These issues must be addressed during
rhinoplasty surgery.

Indications
Indications include (1) aesthetic deformity, (2) patient request for a change in nasal shape, and (3)
improvement of anatomic nasal airway obstruction.

Contraindications
A great majority of rhinoplasties performed are purely elective in nature. As such, the surgeon must
exercise judgment in selecting patients who want to have this type of surgery. This judgment is
guided by surgical principles, the patient's psychologic state, and the ethical consideration of
minimizing any iatrogenic harm to otherwise healthy patients. A brief list of common
contraindications includes the following:
 Unstable mental status (eg, unstable patient with schizophrenia)
Unrealistic patient expectations
Previous rhinoplasty within the last 9-12 months (applies only to major rhinoplasties)
Poor perioperative risk profile
History of too many previous rhinoplasties, resulting in an atrophic skin–soft tissue envelope
and significant scarring
Nasal cocaine users

Workup

References

1. Berger CA, Freitas Rda S, Malafaia O, et al. Prospective study of the surgical techniques
used in primary rhinoplasty on the Caucasian nose and comparison of the preoperative and
postoperative anthropometric nose measurements. Int Arch Otorhinolaryngol. 2015 Jan. 19
(1):34-41. [Medline]. [Full Text].

2. Tebbetts JB. Open and closed rhinoplasty (minus the "versus"): analyzing processes. Aesthet
Surg J. 2006 Jul-Aug. 26(4):456-9. [Medline].

3. Goldwyn RM. Is there plastic surgery in the Edwin Smith Papyrus?. Plast Reconstr Surg.
1982 Aug. 70(2):263-4. [Medline].

4. Sushruta. Sushruta Samhita (English translation by K.L. Bhishagratna). 1998. Calcutta, India:
Kaviraj Kunjalal Publishing; 1907-17.

5. Dieffenbach JF. Die Operative Chirurgie. Liepzig, Germany: F.A. Brockhaus; 1845.

6. Roe JO. The deformity termed "pug-nose" and its correction, by a simple operation. New
York: The Medical Record; 1887. 31: 621.

7. Weir RF. On restoring sunken noses without scarring the face. New York: The Medical
Record; 1892.

8. Tardy ME Jr, Becker D, Weinberger M. Illusions in rhinoplasty. Facial Plast Surg. 1995 Jul.
11(3):117-37. [Medline].

9. Kasperbauer JL, Kern EB. Nasal valve physiology. Implications in nasal surgery. Otolaryngol
Clin North Am. 1987 Nov. 20(4):699-719. [Medline].

10. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault
following rhinoplasty. Plast Reconstr Surg. 1984 Feb. 73(2):230-9. [Medline].

11. Samaha M, Rassouli A. Spreader graft placement in endonasal rhinoplasty: technique and a
review of 100 cases. Plast Surg (Oakv). 2015 Winter. 23 (4):252-4. [Medline].

12. Harel M, Margulis A. Dorsal augmentation with diced cartilage enclosed with temporal fascia
in secondary endonasal rhinoplasty. Aesthet Surg J. 2013 Aug 1. 33(6):809-16. [Medline].

13. Bagheri SC, Khan HA, Jahangirnia A, Rad SS, Mortazavi H. An analysis of 101 primary
cosmetic rhinoplasties. J Oral Maxillofac Surg. 2012 Apr. 70(4):902-9. [Medline].

14. Kim DW, Rodriguez-Bruno K. Functional rhinoplasty. Facial Plast Surg Clin North Am. 2009
Feb. 17(1):115-31, vii. [Medline].

15. Paun SH, Nolst Trenite GJ. Revision rhinoplasty: an overview of deformities and techniques.
Facial Plast Surg. 2008 Aug. 24(3):271-87. [Medline].
 16. Saltman BE, Pearlman SJ. Incidence of alarplasty in primary and revision rhinoplasty in a
private practice setting. Arch Facial Plast Surg. 2009 Mar-Apr. 11(2):114-8. [Medline].

Media Gallery

Basic closed technique for rhinoplasty. Drawing illustrating marginal (inferior dotted line),
cartilage-splitting (blue dotted line), and intercartilaginous (red dotted-line) endonasal
incisions.
Basic closed technique for rhinoplasty. Endonasal incisions. Top dotted line marks the
marginal incision, and the bottom incision marks the intercartilaginous incision. When
combined, these 2 incisions permit the delivery of the alar cartilages outside the nose.
Courtesy of A. John Vartanian, MD.
Basic closed technique for rhinoplasty. Drawing illustrating septal incisions.
Basic closed technique for rhinoplasty. Illustration underscoring the importance of leaving a
robust (>15-mm) dorsocolumellar septal framework when performing septoplasty.
Basic closed technique for rhinoplasty. The caudal edge of the alar cartilages can be
palpated with the back of the scalpel. Courtesy of A. John Vartanian, MD.
Basic closed technique for rhinoplasty. Marginal incision made by gently scoring the
vestibular skin with a sterile blade. Courtesy of A. John Vartanian, MD.
Basic closed technique for rhinoplasty. Drawing relevant anatomic landmarks on the patient's
nose is helpful. Here, the alar cartilages are outlined, along with the tip-defining points,
proposed area of cephalic resection, caudal border of the ascending process of the maxilla,
osseocartilaginous junction, medial canthal line, and placement site for alar batten grafts.
Courtesy of A. John Vartanian, MD.
Basic closed technique for rhinoplasty. Delivery of the alar cartilage can facilitate a number of
maneuvers. An area of cephalic cartilage is marked for excision. The excision is performed at
a slanting angle to prevent sharply demarcated edges. A minimum of 6-8 mm of alar cartilage
is left behind. Courtesy of A. John Vartanian, MD.
Basic closed technique for rhinoplasty. Nasal base resection can narrow the interalar
distance. A more lateral placement of the resection can also reduce alar flaring.
Basic closed technique for rhinoplasty. Most dorsal convexities (humps) have a substantial
cartilaginous component. Cartilaginous dorsal excision is best performed with a sharp No. 15
blade.
Basic closed technique for rhinoplasty. Lateral intraoperative view of a patient demonstrating
medial, lateral (black dots), and intermediate (blue dots) osteotomies. The relative location of
the osteotomies is described in relation to the face (low) and the ceiling (high). Courtesy of A.
John Vartanian, MD.

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Contributor Information and Disclosures

Author

A John Vartanian, MD, MS, FACS Assistant Clinical Professor, Department of Surgery, Division of
Head and Neck, University of California, Los Angeles, David Geffen School of Medicine; Instructor,
Department of Otolaryngology-Head and Neck Surgery, University of Southern California Keck
School of Medicine

A John Vartanian, MD, MS, FACS is a member of the following medical societies: American
Academy of Facial Plastic and Reconstructive Surgery, American College of Surgeons, American
Medical Association, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George Peck, MD

George Peck, MD is a member of the following medical societies: American Society for Aesthetic
Plastic Surgery

Disclosure: Nothing to disclose.

Chief Editor

Mark S Granick, MD, FACS Professor of Surgery, Chief, Division of Plastic Surgery, Rutgers New
Jersey Medical School

Mark S Granick, MD, FACS is a member of the following medical societies: American College of
Surgeons, American Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons,
Northeastern Society of Plastic Surgeons, Phi Beta Kappa, Wound Healing Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Novadaq<br/> for:

Misonix, Inc, medical consultant; Dermasciences, medical consultant; Convatec, medical
consultant; Cytori, medical consultant.

Additional Contributors

Frederick J Menick, MD Clinical Associate Professor, Department of Surgery, Division of Plastic

Surgery, University of Arizona College of Medicine; Facial and Nasal Reconstructive Surgeon,
Tucson, Arizona

Frederick J Menick, MD is a member of the following medical societies: American Society of

Maxillofacial Surgeons, Canadian Society of Plastic Surgeons, American Society for Aesthetic
Plastic Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Author would like acknowledge his mentors (in alphabetical order): Drs. Frank Kamer, Eugene
Tardy, and Dean Toriumi.